Premium Paid Receipt

We confirm the receipt of premium amount of INR 37207 as per below details paid by Azima Gulam Baig for Self and/ or Family and/ or Parents:

Plan Name: Active Care Premier

Plan Name: Plan A Policy Number: 16-20-0008136-00

Type of Plan: Family Floater Proposer Name: Mrs. Azima Gulam Baig

Policy Start Date: 00:00 hrs on 29/04/2022 Policy End Date: 23:59 hrs on 28/04/2023

Receipt No: R8194372

Sr.No Name of the Person Gender Date of Birth Relationship Age CO-Pay (%)

1 Azima Gulam Baig F 08/03/1962 Self 60 NA

Year wise breakup of premium for the purpose of claiming Income Tax deduction u/s 80D (subject provisions of Income Tax Act) is provided as under:

Financial Year Year wise proportionate Premium amount*

2022- 23 37207.00

‘* Premium paid in cash and premium paid towards Personal Accident, Wellness Coach do not qualify for deduction u/ s 80D. Further premium paid for person
other than family member & parents (as defined under Income Tax Act) also don’t qualify for deduction under section 80D.

Amount is rounded off to nearest rupee and is inclusive of all taxes and cesses as applicable. For exact premium, please refer to Section VII of Policy schedule

Note:
1. The year wise deductions as mentioned above are as per provision of Section 80D and this would be subjected to the specified annual limits and other
provisions as applicable for respective years as per applicable provisions of Income Tax Act.
2. Deduction under section 80D of the Act is allowed to the person who pays premium out of his/ her income chargeable to tax.
3. Deduction under section 80D of the Act is available on realization of premium paid by Policyholder.
4. Tax laws are subject to change and any such change could have a retrospective effect. This letter should not be construed as tax, legal or investment opinion
from us. For specific suitability, you are requested to consult your tax advisor.
5. This receipt must be surrendered to the company, in case of cancellation of this policy. In event of incorrect representation of this declaration the liability
shall be upon the policy holder.

For and on behalf of Aditya Birla Health Insurance Co. Limited

Date: 2022-04-29 19:25:23.0

Authorized Signatory
Place: Mumbai